A Pan-European Review of Good Practices in Early Intervention Safeguarding Practice with Children, Young People and Families: Evidence Gathering to Inform a Multi-disciplinary Training Programme (the ERICA Project) in Preventing Child Abuse and Neglect in Seven European Countries

Child maltreatment has detrimental social and health effects for individuals, families and communities. The ERICA project is a pan-European training programme that equips non-specialist threshold practitioners with knowledge and skills to prevent and detect child maltreatment. This paper describes and presents the findings of a rapid review of good practice examples across seven participating countries including local services, programmes and risk assessment tools used in the detection and prevention of child maltreatment in the family. Learning was applied to the development of the generic training project. A template for mapping the good practice examples was collaboratively developed by the seven participating partner countries. A descriptive data analysis was undertaken organised by an a priori analysis framework. Examples were organised into three areas: programmes tackling child abuse and neglect, local practices in assessment and referral, risk assessment tools. Key findings were identified using a thematic approach. Seventy-two good practice examples were identified and categorised according to area, subcategory and number. A typology was developed as follows: legislative frameworks, child health promotion programmes, national guidance on child maltreatment, local practice guidance, risk assessment tools, local support services, early intervention programmes, telephone or internet-based support services, COVID-19 related good practices. Improved integration of guidance into practice and professional training in child development were highlighted as overarching needs. The impact of COVID-19 on safeguarding issues was apparent. The ERICA training programme formally responded to the learning identified in this international good practice review.

AB1540-HPR NURSING INTERVENTIONS FOR RHEUMATIC MUSCULOSKELETAL DISEASES (RMDS) PATIENTS ON BIOLOGIC THERAPY: A SYSTEMATIC LITERATURE REVIEW (SLR)

Background

The support of the Rheumatology nurse to the management of patients who are affected by RMDs, characterized by remission and recrudescence and chronicity, may be strengthened by the investigation of their unmet needs and the identification of the necessary interventions to the continuity and quality of care.

Objectives

The aim of the present SLR is to identify the main nursing interventions to assure quality care in RMDs patients on biologic therapy.

Methods

Study design: a systematic search was conducted from 1990 to 2020 (01/01/1990- 2020/05/07). Inclusion criteria consisted of 1) patients with RMDs in accordance with American College of Rheumatology classification criteria and the American College of Rheumatology/European League against Rheumatism (ACR/EULAR); 2) in therapy with bDMARDS; 3) adult population > 18 years; 4) primary research only; 6) English language; 7) abstract available; and 8) relative quantitative studies; 9) nursing interventions and/or outcomes. Data sources: Medline, CINAHL, PsycINFO and EMBASE databases were used to search for relevant studies. Review methods: using the predetermined inclusion/exclusion criteria, two independent reviewers (MRM, KEA) screened records selected for eligibility based on titles and abstracts. Records meeting the inclusion criteria were retrieved and full texts were further assessed. Critical Appraisal Skills Program (CASP) tools were used to evaluate the quality of the included studies. Data from 8 studies were extracted independently by the reviewers.

Results

1805 articles were retrieved: after the review process, 8 articles met the inclusion criteria resulting in 1 randomized trial, 1 quasi-experimental study and 6 observational studies. The RMDs patient needs emerged concerning the psychosocial domain, the relationship with healthcare facilities and disease follow up to monitor symptoms. Moreover, three major nursing interventions related to these areas were identified: education, patient-centered care and data assessment.

Conclusion

Rheumatology nurses are part of a multidisciplinary team caring for patients on biologic therapy. Starting with accurate initial and ongoing data collection, rheumatology nurses can plan their interventions focusing primarily on patient education and tailored care based on actual needs. Further studies are necessary for research on aspects of patient-centered nursing care, including tele-nursing and Nursing Sensitive Outcomes in RMDs.

References

[1]EULAR, van Eijk-Hustings Y, van Tubergen A, Boström C, Braychenko E, Buss B, Felix J, Firth J, Hammond A, Harston B, Hernandez C, Huzjak M, Korandová J, Kukkurainen ML, Landewé R, Mezieres M, Milincovic M, Moretti A, Oliver S, Primdahl J, Scholte- Voshaar M, de la Torre-Aboki J, Waite-Jones J, Westhovens R, Zangi HA, Heiberg T, Hill J; “Recommendations for the role of the nurse in the management of chronic inflammatory arthritis”, Ann Rheum Dis. 2012 Jan;71(1):13-9. doi: 10.1136/annrheumdis-2011-200185. Epub 2011 Oct 28.

[2]Larsson I. et al,“Randomized controlled trial of a nurse-led rheumatology clinic for monitoring biological therapy”Journal of Advanced Nursing 70(1), 164–175., 2013

[3]Betegnie,A.L. et al, “Why Do Patients with Chronic Inflammatory Rheumatic Diseases Discontinue Their Biologics? An Assessment of Patients’ Adherence Using a Self-report Questionnaire” The Journal of Rheumatology, 2016;43;724-730

[4]Giacomelli R. et al, “Quality of life and unmet needs in patients with inflammatory arthropathies: results from the multicentre, observational RAPSODIA study.” Rheumatology (Oxford) 54(5): 792-797, 2015

[5]Ozkaraman A. et al, “Effect of education and telephone counselling on adherence to treatment and challenges experienced in anti TNF-alfa treatment: a pilot study” Contemporary Nurse, ISSN: 1037-6178 (Print) 1839-3535 (Online), 2019

Disclosure of Interests

None declared

Tumor induced osteomalacia: A single center experience on 17 patients

Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome due to a phosphaturic tumor, which overproduces Fibroblast Growth Factor 23 (FGF-23), causing hyperphosphaturia, hypophosphatemia, low 1,25(OH)₂D and osteomalacia. Tumor localization is critical, diagnostic delay ranges from 2.5 to 28 years and to date surgical removal is considered effective treatment. We retrospectively evaluated patients with definite diagnosis of TIO referred to a tertiary Rheumatology Center between September 2000 and May 2020, investigating clinical management and disease outcome. We included 17 patients: 10 (58.8%) were females, mean age at diagnosis was 55.3 ± 13.9 years (mean ± standard deviation), with a diagnostic delay from symptoms onset to tumor detection of 6.6 ± 6.25 years. Biochemical data were: serum phosphorus 1.3 ± 0.4 mg/dL (Reference Range: 2.5-4.6), serum 1,25(OH)₂D 31.8 ± 22.9 ng/mL (RR: 25-86), intact FGF-23, 358.9 ± 677 pg/mL (RR: 25-45); 24 h-Urine Phosphorus was increased in only 2 patients, while tubular reabsorption of phosphate (TRP) was decreased in all patients confirming a renal phosphate wasting. In 2013 ⁶⁸Ga- DOTA-based PET/CT was introduced in routinely practice and diagnostic delay was consistently reduced (from 8.6 ± 7.9 to 4.3 ± 2.4 years). Thirteen patients underwent surgery, one patient underwent radiofrequency ablation; 3 patients, not eligible for surgery, were treated only with supplements of phosphorus and calcitriol. One was started on Burosumab after several unsuccessful surgical attempts. After surgery or ablation, 8 patients had complete remission, 3 TIO persistence, and 3 had overtime relapse. Relapses were observed only in patients who previously underwent closed biopsy. To our knowledge, this is the widest European cohort of TIO patients in the last two decades. We confirm a usual diagnostic delay and recommend a stepwise diagnostic approach. Tumor biopsy is not recommended due to the potential cell spilling. Surgery is generally considered a definitive treatment, even though other approaches have been successful in curing TIO. Active surveillance on possible recurrence is always needed. Burosumab appears a promising therapy.

[18F]FDG hypermetabolisms of the spleen and/or bone marrow: indirect signs of bacteremia

Funding Acknowledgements

Type of funding sources: None.

Aim

Recently hypermetabolisms of the spleen and/or bone marrow has been proposed as an indirect sign of infective endocarditis (IE), useful to reinforce the suspicion of IE in the absence of any other infectious, inflammatory, or malignant disease. The purpose of this study is to determine whether hypermetabolisms of the spleen and/or bone marrow are indirect signs of bacteremia rather than of IE, specifically.

Materials and Method

In this work we retrospectively evaluated a series 240 patients who performed between January 2015 to December 2020 [18F]FDG PET/CT (Discovery 710 GE) for suspected infection. In particular, 80 pts had infections from different origin and a positive blood culture (PBC), 80 pts presented localized infection, but negative blood culture (IDBCN) and 80 pts were classified as definite IE (IED) according to the 2015 ESCcriteria. [18F]FDG SUVmax SUVmean in bone marrow, spleen and liver were measured drawind a 14 cm3 regions of interest (ROIs) positioned close to the centers of the spleen and of the right liver lobe, but excluding abscess and/or ischemic lesions., as previously described (Caroline Boursier et al. ; Jordy P.Pijl et al.). BM SUVmax and SUVmean was obtained from ROIs placed on the bodies of each of the five lumbar vertebrae, excluding any damaged vertebra. BM to liver SUV ratios (BLR) and spleen to liver SUV ratios (SLR) were calculated. Kruskal-Wallis tests and the Dunn’s test procedure for multiple comparison were performed using JMP Statistical Discoverytm.

Results

No significant difference among the three groups of SUVmax/mean or in SLR were found. Nevertheless, by grouping patients for the presence of positive blood culture (142 pts) or negative blood culture (98 pts), irrespectively from the final diagnosis a significant associations of SLR was found (p = 0.0070). No significant associations were found with BLR.

Conclusions

Based on our data SLR in seems to represent an indirect signs of bacteremia, rather than IE.

AB0256 BARICITINIB (BARI) VERSUS BIOLOGICS IMPACT ON STEROID TAPERING IN RHEUMATOID ARTHRITIS (RA)

Background:

Biologic and target synthetic disease modifying anti-rheumatic drugs (bDMARDs and tcDMARDs) are recommended to control RA disease activity, pain and steroid use. Following randomized clinical trials (RCTs) and their post-hoc analyses, the Janus Kinase Inhibitor tsDMARDs BARI was superior to reference bDMARD Adalimumab in reducing disease activity, pain and functional disability. In addition, BARI monotherapy also determined more significant pain reduction and functional improvement when compared to Tocilizumab monotherapy (3).

Objectives:

to confirm RCT results in a real-life clinical setting, with focus on disease activity, pain, functional disability and steroid tapering, when comparing BARI to bDMARDs for the treatment of active RA.

Methods:

RA patients starting BARI or a bDMARD for active RA were retrospectively evaluated from June 2019 to June 2020. Disease activity (DAS28CRP, SDAI, CDAI), pain visual analogic scale (pain_VAS), functional disability (HAQ) assessments and mean prednisone dosage (pred_dose) were collected at baseline (BL), 3 months (3M) and 6 months (6M) after BARI/bDMARD initiation. The changes of the outcome measures were evaluated between BL-3M, 3M-6M and BL-6M, as well as between BARI and bDMARDs groups. Finally, we assessed the variables associated with prednisone tapering in the whole population.

Results:

90 out of 100 RA patients evaluated (baseline: age 57±12 years, disease duration 131±100 months, DAS28PCR 4.8±1.0, pain_VAS 61±23 mm, prednisone dose 5.5±5.3 mg) were eligible for the study; 49 received BARI and 41 bDMARDs (17 abatacept, 12 TNF inhibitors, 11 tocilizumab, 1 rituximab). At BL, the two groups did not differ statistically in terms of age, sex, disease duration, disease activity, pain_VAS, previous bDMARD failure or ts/bDMARD naive, concomitant conventional synthetic DMARDs treatment, pred_dose. Both BARI and bDMARDs determined a significant reduction in activity scales and HAQ when comparing BL-3M and BL-6M, with only pain_VAS and pred_dose showing a significant decrease in the 3M-6M interval. When comparing the two groups, BARI showed a significantly higher reduction of pred_dose (-3.2±5.1 vs -1.7±3.7 mg at BL-3M, and -4.1±5.3 vs -1.9±4.6 mg at BL-6M), which was not significant after adjusting for BL pred_dose. No other difference was seen when the two groups, including the numerically higher reduction of pain_VAS in the BARI group (-29±28 vs -20±27 mm at BL-3M and -35±25 vs -30±28 mm at BL-6M comparison). The analysis of the predictors for steroid tapering (Δmean_pred) in the two intervals, showed that BL DAS28PCR, DAS28PCR BL-3M change and BL pred_dose were associated with BL-3M Δmean_pred, while 3M pain_VAS and 3M pred_dose were associated with 3M-6M Δmean_pred.

Conclusion:

Although limited by the small samples and the retrospective nature, our real-life comparison shows similar efficacy of BARI and bDMARDs in terms of disease activity control, functional disability and pain. In addition, the treatment with BARI or bDMARD did not influence the steroid tapering, which was driven mostly by its initial dose, disease activity and pain. Larger real-life multi-center studies are warranted to confirm our results.

References:

[1]Taylor PC et al. Baricitinib versus Placebo or Adalimumab in Rheumatoid Arthritis. N Engl J Med. 2017 Feb 16;376(7):652-662.

[2]Fautrel B et al. Effect of Baricitinib and Adalimumab in Reducing Pain and Improving Function in Patients with Rheumatoid Arthritis in Low Disease Activity: Exploratory Analyses from RA-BEAM. J Clin Med. 2019 Sep 5;8(9):1394.

[3]Fautrel B et al. Comparative effectiveness of improvement in pain and physical function for baricitinib versus adalimumab, tocilizumab and tofacitinib monotherapies in rheumatoid arthritis patients who are naïve to treatment with

Disclosure of Interests:

Laura Cometi: None declared, Cosimo Bruni Speakers bureau: Actelion, Consultant of: Eli Lilly, Grant/research support from: Fondazione Italiana Ricerca sull’Artrite (FIRA), Gruppo Italiano lotta alla Sclerodermia (GILS), New Horizon Fellowship, European Scleroderma Trials and Research (EUSTAR) group, Foundation for Research in Rheumatology (FOREUM)., Lorenzo Tofani: None declared, Giulia Tesei: None declared, Francesca Nacci: None declared, Ginevra Fiori: None declared, Francesca Bartoli: None declared, Marco Matucci-Cerinic Speakers bureau: Biogen Italia, Actelion, Bayer, Boehringer Ingelheim, CSL Behring, Eli-Lilly, Consultant of: Biogen Italia, Actelion, Bayer, Boehringer Ingelheim, CSL Behring, Eli-Lilly, Grant/research support from: Biogen Italia, Actelion, Bayer, Boehringer Ingelheim, CSL Behring, Eli-Lilly,

POS1495-HPR THE EXPERIENCE OF A RHEUMATOLOGY UNIT DURING THE COVID19 LOCKDOWN: TELEMEDICINE ALLOWS A SAFE FOLLOW UP OF PATIENTS WITH RHEUMATIC DISEASES

Background:

In March this year, most of the routine activities were cancelled during the streaming of the pandemic in Italy. This prompted a pragmatic reorganization of the traditional care model of nursing and medicine, to quickly give an efficient clinical response. During the first phase of the pandemic, outpatient visits dropped by more than 60%, forcefully shifting to telemedicine to assure continuity of care despite the lockdown.

Objectives:

The aim of the present work was to describe the strategy adopted during and immediately after the lockdown to assure the follow up of patients and the maintenance of their treatment in an outpatient “virtual” telemedicine clinic dedicated to RDs.

Methods:

the patient flow to a rheumatology division during the lockdown was evaluated retrospectively from March to September 2020 in accordance with local restrictions, and three periods are described.

Results:

653/913 (71.5%), 542/542 (100%) and 1.048/1.048 (100%) infusion activities scheduled were performed at the centre for daily infusion and pre-infusion assessment, respectively during the 1st, 2nd and 3rd period. In the outpatient clinic during the 1st period, 96.96% of the cases was shifted to Telemedicine, which decreased to 52.45% in the 2nd period; while in the 3rd period, 97.6% of the performances were carried out at the clinic. Diagnostic procedures, such as ultrasound, capillaroscopy, and joint injection were generally postponed during the 1st period, reduced drastically during the 2nd and performed regularly during 3rd period. Ulcer treatment and the Clinical Trial Unit never stopped their activity. The flow of the activity of the outpatient clinic and the day hospital is represented as monthly trends in graph 1 (See Graph 1).

Conclusion:

Our data show the feasibility of Telemedicine in a lockdown condition. Shifting stable patients to Telemedicine has the potentiality to minimize the risk of contagion and allow continuity of care. In the future, the use of Telemedicine for specific clinical uses might assure patient assistance also in non-pandemic conditions.

References:

[1]Rawaf S, Allen LN, Stigler FL et al. Lessons on the COVID-19 pandemic, for and by primary care professionals worldwide. Eur J Gen Pract. 2020 Dec;26(1):129-133. doi: 10.1080/13814788.2020.1820479. PMID: 32985278.

[2]McDougall JA, Ferucci ED, Glover J, et al. Telerheumatology: A Systematic Review. Arthritis Care Res (Hoboken). 2017 Oct;69(10):1546-1557. doi: 10.1002/acr.23153. Epub 2017 Aug 22. PMID: 27863164; PMCID: PMC5436947.

[3]Romão VC, Cordeiro I, Macieira C, Oliveira-Ramos F, Romeu JC, Rosa CM, Saavedra MJ, Saraiva F, Vieira-Sousa E, Fonseca JE. Rheumatology practice amidst the COVID-19 pandemic: a pragmatic view. RMD Open. 2020 Jun;6(2):e001314. doi: 10.1136/rmdopen-2020-001314. PMID: 32584782; PMCID: PMC7425193.

Characters from table content including title and footnotes:

Graph 1.

Monthly trend for telemedicine and visits during the SARS Cov2 emergency

Acknowledgements:

The project (Telereuma) has been supported by an unrestricted grant of Biogen, BMS, and Novartis.

Disclosure of Interests:

None declared

POS0618 PERSISTENCE OF REMISSION AFTER TAPERING OF GOLIMUMAB IN INFLAMMATORY JOINT DISEASE (IJD)

Background:

In refractory IJD, remission may be obtained with antiTNFa drugs and other biological disease modifying anti-rheumatic drugs (bDMARDs). The last EULAR recommendations suggest tapering of bDMARD when remission persists1. However, best timing and modality of tapering are uncertain and specific knowledge on patients’ characteristics associated to a better outcome is still lacking.

Objectives:

To evaluate the persistency of remission after increasing the interval between injections of Golimumab in a group of patients affected by rheumatoid arthritis (RA), psoriatic arthritis (PsA), ankylosing spondylitis (AS) and juvenile idiopathic arthritis (JIA) and to identify any variables associated to disease flare after tapering.

Methods:

Between 2011 and July 2020, 80 patients affected by RA, PsA, AS and JIA treated with Golimumab were enrolled. Their demographic and clinical data, including inflammation (ESR and cRP) and clinimetric indices (DAS28 or BASDAI), were collected at baseline and during the follow up visit (T1). In 22/80 patients that reached clinical remission at T1, the time between Golimumab injections has been prolonged (mean time between injection: 43.7 days); ESR and cRP, DAS28/BASDAI, and time since the start of the tapering (weeks) were evaluated in the next control visit (T2).

Results:

80 patients were enrolled (32 male, mean age 50.6 years +/- 13.91), 34 AS, 33 PsA, 9 RA and 4 JIA. At baseline they have an active disease with a DAS 28 of 4.74+/-0.85 and a BASDAI of 5.23+/- 1.31. At T1, 60/80 patients were in remission (75%), with a mean DAS 28 of 1.84+/- 0.6 and an average BASDAI of 1.32+/-0.6, and 22/60 patients started drug tapering. At T2, 20/22 patients (91%) were in remission, (DAS 28 1.9+/-0.49, BASDAI of 0.8+/- 0, 67). A significantly higher BASDAI was observed at T1, even though in the range of absence of disease activity (2.2, +/- 0.28 vs 0.58, +/- 0.47; p <0.001) in patients who, after extending the therapeutic interval (T1) were no longer in remission at T2. Patients with a flare of disease activity (2/22) were taken back to the 28 days window of Golimumab with a prompt recovery of disease remission. Out of the 38 patients maintained at the standard dose, 4 experienced a disease flare with necessity to switch or swope bDMARD, with a retention rate in this group of 90%. Difference of retention rate between patients on standard vs reduced dose was not statistically significative.

Conclusion:

Tapering of Golimumab was successful in 91% of the cases without flare. Moreover, the prolongation of the increase of the treatment window provided the same result as that obtained in patients that continued in the standard time window. This evidence suggests that the extension of the gap between Golimumab administrations may be feasible and safely applied in practice.

References:

[1]Smolen JS, Landewé RBM, Bijlsma JWJ, et al EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update Annals of the Rheumatic Diseases 2020;79:685-699.

Disclosure of Interests:

None declared

AB0281 SAFETY AND RETENTION RATE AFTER SWITCHING FROM ETANERCEPT ORIGINATOR (ETN) TO ETANERCEPT BIOSIMILAR (SB4) IN INFLAMMATORY JOINT DISEASES: DATA FROM REAL LIFE

Background:

SB4 in now commonly used in the treatment of inflammatory joint diseases, with evidence of efficacy and persistence up to 12 months from switching in both randomized controlled trials in Rheumatoid Arthritis (RA), Psoriatic Arthritis (PsA) and Ankylosing Spondylitis (AS).

Objectives:

we investigated the safety and retention rate of SB4 at 6, 12 and 18 months after switching from ETN in two rheumatology departments in our region.

Methods:

adult patients with RA, PsA, AS, Juvenile Idiopathic Arthritis (JIA) and other rheumatic diseases treated with ETN for at least 6 months, switched to SB4 in stable clinical conditions, were eligible for this retrospective evaluation. Data on adverse events (in particular infectious events), loss of efficacy (articular, cutaneous, ocular or intestinal disease re-activation) and persistence on treatment were collected since latest available follow-up. Retention rate, reason for discontinuation and subsequent management data were collected at 6, 12, 18 months.

Results:

220 patients (142 females, mean age 58+-7 years, disease duration 12+-4 years, ETN duration 7+-4 years) were enrolled, with median follow up of 12.1 (9.7-15.8) months duration; ETN was used in different biologic DMARDs treatment lines (first 76.8%, second 17.7%, third 3.2 %, fourth 2.3%). Study population was composed of 85 RA, 81 PsA, 33 AS, 14 JIA and 7 other conditions (mostly scleroderma). In the follow-up, 50 patients (22.7%) presented with at least one non-serious adverse event, with 36 (16,4%) disease re-activation (mostly articular) and 30 (13,6% - 11 for safety and 19 loss of efficacy) SB4 interruptions. Retention rates were 99.1 (210/212) at 6, 90.9% (150/165) at 12 and 81.5% (53/65) at 18 months respectively. Back-switch to ETN was performed in 17/30 cases, the remaining cases were managed with change of bDMARD or csDMARD). Age was the only significant predictor of SB4 interruption at 6 months (OR 1.058, 95%CI 1.007-1.112, p=0.026), while disease, bDMARD line, csDMARD combination, gender, disease duration or ETN duration did not influence retention rates at 6, 12 or 18 months.

Conclusion:

our real-life data confirm the safety profile of switching from ETN to SB4. In our patients, the data show a higher retention rate, when compared to other-real life registries data (1,2)

References:

[1]Ebbers HC et al. Real-World evidence on Etanercept Biosimilar SB4 in Etanercept-Naïve or Switching Patients: A Systematic Review. Rheumatol Ther. 2019 Sep;6(3):317-338.

Disclosure of Interests:

Cosimo Bruni Speakers bureau: Actelion, Eli Lilly, Stefano Gentileschi: None declared, Marco Capassoni: None declared, Giovanni Pacini: None declared, Marco Bardelli: None declared, Caterina Baldi: None declared, Lorenzo Tofani: None declared, Laura Cometi: None declared, Francesca Nacci: None declared, Francesca Bartoli: None declared, Ginevra Fiori: None declared, Luca Cantarini: None declared, Serena Guiducci: None declared, Bruno Frediani: None declared, Marco Matucci-Cerinic Grant/research support from: Actelion, MSD, Bristol-Myers Squibb, Speakers bureau: Acetelion, Lilly, Boehringer Ingelheim

THU0528 NAILFOLD VIDEOCAPILLAROSCOPY REPORTING IN CLINICAL RESEARCH: INTERNATIONAL DELPHI BASED CONSENSUS

Background:

Nailfold capillaroscopy (NVC), a non-invasive technique to assess microcirculation, is increasingly being incorporated into rheumatology routine clinical practice. Currently, the degree of description of NVC methods varies amongst research studies, making interpretation and comparison between studies challenging. In this field, an unmet need is the standardization of items to be reported in research studies using NVC.

Objectives:

To perform a Delphi consensus on minimum reporting standards in methodology for clinical research, based on the items derived from a systematic review focused on this topic.

Methods:

The systematic review of the literature on NVC methodology relating to rheumatic diseases was performed according to PRISMA guidelines (PROSPERO CRD42018104660) to July 22nd2018 using MEDLINE, Embase, Scopus. Then, a three-step web-based Delphi consensus was performed in between members of the EULAR study group on microcirculation in rheumatic diseases and the Scleroderma Clinical Trials Consortium. Participants were asked to rate each item from 1 (not appropriate) to 9 (completely appropriate).

Results:

In total, 3491 references were retrieved in the initial search strategy, 2862 were excluded as duplicates or after title/abstract screening. 632 articles were retrieved for full paper review of which 319 fulfilled the inclusion criteria. Regarding patient preparation before the exam, data were scarce: 38% reported acclimatization, 5% to avoid caffeine and smoking, 3% to wash hands and 2% to avoid manicure. Concerning the device description: 90% reported type of instrument, 77% brand/model, 72% magnification, 46% oil use, 40% room temperature and 35% software for image analysis. As regards to examination details: 76% which fingers examined, 75% number of fingers examined, 15% operator experience, 13% reason for finger exclusion, 9% number of images, 8% quality check of the images and 3% time spent for the exam. Then, a three-round Delphi consensus on the selected items was completed by 80 participants internationally, from 31 countries located in Australia, Asia, Europe, North and South America. Some items reached the agreement at the second round (85 participants), and other items were suggested as important to consider in a future research agenda (e.g. temperature for acclimatization, the impact of smoking, allergies at the application of the oil to the nailbed, significance of pericapillary edema, methods of reporting hemorrhages, ramified and giant capillaries). The final agreement results are reported below:

Conclusion:

On the basis of the available literature the description of NVC methods was highly heterogeneous and individual published studies differed markedly. These practical suggestions developed using a Delphi process among international participants provide a guidance to improve and to standardize the NVC methodology in future clinical research studies.

Disclosure of Interests:

Francesca Ingegnoli: None declared, Tommaso Schioppo: None declared, Ariane Herrick: None declared, Alberto Sulli Grant/research support from: Laboratori Baldacci, Francesca Bartoli: None declared, Nicola Ughi: None declared, John Pauling: None declared, Maurizio Cutolo Grant/research support from: Bristol-Myers Squibb, Actelion, Celgene, Consultant of: Bristol-Myers Squibb, Speakers bureau: Sigma-Alpha, Vanessa Smith Grant/research support from: The affiliated company received grants from Research Foundation - Flanders (FWO), Belgian Fund for Scientific Research in Rheumatic diseases (FWRO), Boehringer Ingelheim Pharma GmbH & Co and Janssen-Cilag NV, Consultant of: Boehringer-Ingelheim Pharma GmbH & Co, Speakers bureau: Actelion Pharmaceuticals Ltd, Boehringer-Ingelheim Pharma GmbH & Co and UCB Biopharma Sprl

THU0421 TUMOR-INDUCED OSTEOMALACIA: DATA FROM A MONOCENTRIC EXPERIENCE ON 16 PATIENTS

Background:

Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome due to a phosphaturic tumor, which overproduces fibroblast growth factor-23 (FGF-23), causing hyperphosphaturia, hypophosphoremia, low 1,25(OH)2VitD3and osteomalacia. Locating the tumor is critical, because lesions are typically small, benign mesenchymal tumors, anywhere in the body; the delay between onset of symptoms and diagnosis ranges from 2.5–28 years. Surgical removal is the only effective therapeutic approach.

Objectives:

To retrospectively evaluate patients affected by TIO, investigating clinical management and disease outcome.

Methods:

We retrospectively collected data of patients affected by TIO referred to a tertiary Rheumatology Center between Sep 2000 and Jan 2020.

Results:

We included 16 patients with a definite diagnosis of TIO, mean age±standard deviation 62.4±14.6 yrs, 56.2% females, mean age at symptoms onset 48.0±14.3 yrs (53.8±13.1 at diagnosis). Mean diagnostic delay between symptoms onset and tumor detection was 6.8±6.4 yrs. All patients complained bone pain, muscle weakness, and fractures before diagnosis of TIO. Biochemical findings were: mean serum Phosphorus (PS) 1.4±0.4 mg/dL (reference range (RR) 2.5-4.6), mean serum Calcium 9.4±0.7 mg/dL (RR 8.4-10.2), mean serum 1,25(OH)2VitD330.5±23.4 ng/L (RR 25-86). Intact-FGF-23 was dosed in 9 patients, always resulting elevated: mean 396.6±707.3 pg/mL (RR 25-45). PTH was increased in 30% of cases, while serum alkaline phosphatase was increased in 87.5%. 24h-Urine Phosphorus (PU) was increased in only 13% of patients, but, when renal phosphate wasting by tubular reabsorption of phosphate (TRP) was calculated, PU resulted increased in all.

Tumor was localized in all cases (Fig.1) and were localized in bone and soft tissue, by using functional imaging, followed by anatomical techniques. Before the introduction in routinely practice of68Ga-DOTATATE-PET-CT in 2013, Octreoscan-SPECT/CT and18F FDG-PET were used as imaging modalities. Since 2013, diagnostic delay consistently reduced, from 8.6±8.3 yrs (7 patients) to 4.5±2.6 yrs (9 patients), confirming higher diagnostic accuracy of68Ga-DOTATATE-PET-CT.

Figure 1.

13 patients underwent surgery; in two cases surgery was not possible due to tumor location, so pharmacological support with phosphate supplements and calcitriol was started; a patient underwent to TC-guided radiofrequency ablation. After surgery, 7 patients experienced a complete remission, 3 had a persistence of the disease, and 3 an overtime relapse, even after a longstanding normalization of PS (6 years). After surgical tumor removal, PS significantly increased in few days (from 1.36±0.39 to 2.9±1.1, p=0.0001), while iFGF-23 levels tended to rapidly decreased (from 396.6±707.3 to 62.8±78.4). Before the introduction of68Ga-DOTATATE-PET-CT, 6 patients underwent to imaging-guided closed biopsy to confirm tumor localization; by using68Ga-DOTATATE-PET-CT only 2 subjects had closed biopsy. Furthermore, in our population only patients who had biopsy to detect the lesion (7 patients) had relapses compared to patients who did not.

Conclusion:

To our knowledge, this is the widest European cohort of patients affected by TIO reported in the last two decades. We confirm an important delay between symptoms onset and diagnosis. To locate tumor, a stepwise approach is recommended, starting with a thorough medical history and physical examination, followed by functional imaging, preferring68Ga-DOTATATE-PET-CT. Tumor biopsy is not recommended due to the potential cell spilling. Surgery is considered the only definitive treatment, aiming to a wider excision. Active surveillance is always needed, due to the possible relapses, even after a long period of complete clinical and biochemical remission.

Disclosure of Interests: :

Chiara Crotti: None declared, Francesca Bartoli: None declared, Maria Manara Consultant of: Consultant and/or speaker for Eli-Lilly, MSD, Sanofi-Genzyme, Novartis, Alfa Wasserman and Cellgene, Speakers bureau: Consultant and/or speaker for Eli-Lilly, MSD, Sanofi-Genzyme, Novartis, Alfa Wasserman and Cellgene, Primo Andrea Daolio: None declared, Francesca Zucchi: None declared, Roberto Caporali Consultant of: AbbVie; Gilead Sciences, Inc.; Lilly; Merck Sharp & Dohme; Celgene; Bristol-Myers Squibb; Pfizer; UCB, Speakers bureau: Abbvie; Bristol-Myers Squibb; Celgene; Lilly; Gilead Sciences, Inc; MSD; Pfizer; Roche; UCB, Luigi Sinigaglia: None declared, Massimo Varenna: None declared

THU0360 EFFICACY OF A SELF-TREATMENT PROTOCOL FOR FACE AND TEMPOROMANDIBULAR JOINTS REHABILITATION IN SYSTEMIC SCLEROSIS (SSC)

Background:

In SSc, skin involvement of the face is frequent and extremely disabling, resulting in limited mouth opening, an altered dentition, difficulty in teeth care, as well as having a strong impact on the emotional and psychological well-being, thus impairing quality of life.

Objectives:

to evaluate the efficacy of a self-treatment protocol (created by AMURR A Multidisciplinary Association of Rheumatological Rehabilitation) for face and tempomandibular joints (TMJs) rehabilitation with two devices used in the dental field.

Methods:

40 SSc patients (37 female and 3 male) with a mouth opening ≤ 40 mm, were recruited and randomized in two groups of treatment: Group 1 (20 patients: mean age 50,650 yrs ± 13,937 SD, mean disease duraton 10,45 yrs ± 7,877 SD, opening mouth 32,250 mm ± 5,590 SD) treated with a home self-treatment protocol consisting of 23 exercises carried out at home in front of a mirror, 22/23 exercises were performed once a day, one of these using a device to obtain uniform stretching of the buccal rhyme, another one usingused three times a day to reduce tension of muscles of the TMJs, facilitating the mouth opening; group 2 (20 patients: mean age 58,05 yrs ± 18,103 SD, mean disease duration 17,4 yrs ± 15,017 SD, opening mouth 34,950 mm ± 5,753) without physical rehabilitation, only drugs as treatments of SSc and its complications. All patients underwent a baseline (T0) and 45 days (T1) clinimetric assessment by self-assessment of quality of life with SF-36 (Short-Form 36 Health Survey), of the degree of disability of the mouth with MHISS (of the Mouth Handicap in Systemic Sclerosis scale), Muscle pain evaluated by numerical rating scale (NRS) of the temporomandibular joint with TMD (Temporo mandibular Disorders), evaluation of mouth opening and ROM of the cervical spine. Statistical analysis was performed using the t-test or the Mann-Whitney test for assessing changes in all measurement scales between treatment groups.

Results:

The protocol of home physiotherapy exercises resulted in a statistically significant improvement in the treated group compared to group 2 both for mouth opening (T0: 32,250 ± 5,590, T1: 35,650 ± 6,046) vs (T0: 34,950 ± 5,753 T1: 34,300 ± 6,001) (p<0.001), cervical flexion (T0: 2,950 ± 1,939 T1: 1.700 ± 1,525) vs (T0: 4,450 ± 2,282 T1:4,075 ± 2,238) (p<0.01), cervical extension (T0: 17,025 ± 1,895 T1: 17,625 ± 1,605) vs (T0: 17,050 ± 2,089 T1: 16,525 ± 3,110) (p<0.05), cervical right lateral flexion (T0: 14,075 ± 2,386 T1:13,400 ± 2,431) vs (T0: 14,200 ± 1,765 T1: 14,425 ± 1,742) (p<0.01), cervical right rotation (T0: 14,200 ± 3,416 T1:13,750 ± 3,206) vs (T0: 14,900 ± 1,683 T1: 15,550 ± 2,188) (p<0.01), cervical left rotation (T0: 14,725 ±3,640 T1:14,450 ± 3,710) vs (T0: 15,900 ± 2,614 T1: 16,450 ± 2,964) (p<0.05), mouth disability at MHISS (T0: 19,100 ± 10,356 T1: 16,000 ± 9,989) vs (T0: 20,950 ± 9,950, T1: 21,100 ± 10,775) (p<0.01).

Conclusion:

The use of the home exercises protocol associated with the two devices has shown a significant improvement of the disability linked to skin involvement of the face. This highlights the fundamental role that home rehabilitation self therapy has in practice. These data will need to be confirmed in a larger cohort of patients

Disclosure of Interests:

Mauro Passalacqua: None declared, Cristian Foggi: None declared, Nicola Mauro: None declared, Lorenzo Tofani: None declared, Serena Guiducci: None declared, Cosimo Bruni Speakers bureau: Actelion, Eli Lilly, Gemma Lepri: None declared, Jelena Blagojevic: None declared, Khadija El Aoufy: None declared, Ginevra Fiori: None declared, Francesca Bartoli: None declared, Susanna Maddali Bongi: None declared, Marco Mitola: None declared, Marco Gizduloch: None declared, Marco Matucci-Cerinic Grant/research support from: Actelion, MSD, Bristol-Myers Squibb, Speakers bureau: Acetelion, Lilly, Boehringer Ingelheim, Silvia Bellando Randone: None declared

AB0239 EFFECTS OF DYSMETABOLISMS AND COMORBIDITIES ON THE EFFICACY, SAFETY AND RETENTION RATE OF BIOLOGICAL DMARDS (bDMARD) IN INFLAMMATORY JOINT DISEASES

Background:

bDMARDs have an effect on glucose homeostasis (1), lipoproteins profile (2; 3) and blood pressure (4). However, with the exception of obesity (5; 6), there are no clear data on how bDMARDs work in patients who already have or develop metabolic comorbidities and whether these conditions can impact on their efficacy and safety profile.

Objectives:

to evaluate, in chronic inflammatory joint diseases, the effect of arterial hypertension (AH), dyslipidemia (DYS) and diabetes mellitus (DM) on efficacy, safety and retention rate of first-line bDMARDs therapy.

Methods:

a retrospective observational study on the clinical charts of Rheumatoid Arthritis (RA), Psoriatic Arthritis (PsA) or Ankylosing Spondylitis (AS), treated with first on-label bDMARD was performed. Data on adverse events, efficacy and comorbidities at the baseline visit in which the bDMARD was prescribed (BL), the visit performed after 6 months of therapy (6M), and the last visit on treatment (LoT) were collected.

Results:

383 patients (41,8% RA, 33,4% PsA and 24,8% AS) were included in the study, with the predominance of females (F: 67,36%, M: 32,64%; mean age 51,67 ± 15,11 years). Our data show that the presence of comorbidities had no influence on efficacy of bDMARD, while patients who had DYS at BL manifested a higher rate of systemic adverse events either in the first 6 months of therapy (58,9% vs 43,7%, p=0,040) and also later on (80,36% vs. 66,67%, p=0,046). In addition, patients who developed DYS and AH after the 6M visit reported a higher rate of systemic adverse events at LoT visit, compared to others (DYS: 97,8% vs 66,7%, p<0,001; AH: 86,9% vs 65,2%, p=0,031). For what concerns the retention rate, patients who developed DYS or AH during bDMARD treatment continued the drug for a longer period of time (DYS 95,5 vs 19,6 months, p<0,001; AH 72,1 vs 23,4 months, p<0,001). In particular, patients with AH who concomitantly carried out therapy with ACE-inhibitors (ACEi) and/or angiotensin II receptor blockers (ARB) continued bDMARDs for nearly 20 more months than patients who were not exposed to these drugs (40,5 vs 23,4 months, p=0,001) and more frequently maintained the bDMARDS at LoT (59,42% vs. 47,53%). In case of withdrawal in the ACEi/ARB exposed cohort, this was due to well-being and disease remission rather than inefficacy or adverse reaction (p=0,025). In dyslipidemic patients treated with statins, data showed that bDMARDs were continued for a longer time than in DYS patients treated with other anti dyslipidemic therapies (41,09 vs. 26,50 months, p=0,042).

Conclusion:

our data suggest that AH and DYS may be associated with higher frequency of adverse events but a better drug retention. The combination of bDMARD and ACEi/ARB may determine a better control of the inflammatory process by inhibition of angiotensin II, favouring the achievement of remission. In AH patients on bDMARDs, ACEi and ARB could therefore represent an useful anti-hypertensive drug choice. Similarly, statins could be the treatment of choice in DYS patients.

References:

[1]Gonzalez-Gay MA, et al. Clin Exp Rheumatol. 2006.

[2]Pollono EN, et al. Clin Rheumatol. 2010

[3]van Sijl AM, et al. Semin Arthritis Rheum. 2011.

[4]Yoshida S, et al. J Hum Hypertens. 2014.

[5]Gremese E, et al. Arthritis Care Res (Hoboken). 2013.

[6]Heimans L, et al. Arthritis Care Res (Hoboken). 2013.

Disclosure of Interests:

Laura Cometi: None declared, Cosimo Bruni Speakers bureau: Actelion, Eli Lilly, Nicolò Chiti: None declared, Lorenzo Tofani: None declared, Francesca Nacci: None declared, Francesca Bartoli: None declared, Silvia Bellando Randone: None declared, Ginevra Fiori: None declared, Serena Guiducci: None declared, Marco Matucci-Cerinic Grant/research support from: Actelion, MSD, Bristol-Myers Squibb, Speakers bureau: Acetelion, Lilly, Boehringer Ingelheim

AB0361 EFFICACY AND SAFETY OF BARICITINIB (BARI) IN RHEUMATOID ARTHRITIS(RA): CLINICAL AND ULTRASOUND EVALUATION IN REAL LIFE

Background:

Remission or low disease activity (LDA) are the ultimate goals of both conventional synthetic (csDMARD), target synthetic and biologic disease-modifying anti-rheumatic drugs (bDMARD) in treating RA. Janus Kinase (JAK) inhibitors are nowadays part of tsDMARDs, with BARI as an oral selective JAK1-2 inhibitor. Ultrasound (US) is a valuable imaging tool for detecting inflammatory joint changes and monitoring RA patients. The US7 score (US7) is a semiquantitative score including grayscale (GS) and power Doppler (PD) measurements of synovitis and tenosynovitis in 7 joints of the clinically dominant hand and foot.

Objectives:

to evaluate real life efficacy and safety of BARI 4 mg in RA patients using clinical, clinimetric and US evaluation.

Methods:

adult RA patients starting BARI were eligible. DAS28ESR, CDAI, SDAI, painVAS, HAQ, COCHIN, laboratory parameters and US7 were performed/collected at baseline (BL) and after 3 and 6 months. Adverse events (AE) and concomitant medications were recorded. Responder/non responder status was determined using DAS28ESR improvement according to the EULAR Response Criteria at 3 months. Moreover, SDAI clinical remission or LDA (remission: SDAI≤3,3; LDA:3,3<SDAI≤11) were calculated at 3 and 6 months.

Results:

43 patients (12 csDMARD and 31 bDMARD failure) were enrolled, with 30 patients starting BARI in combination with a csDMARDs. BL painVAS was 68±23mm and disease activity was moderate to severe according to DAS28VES, CDAI and SDAI. BARI determined a significant improvement of every disease activity composite score and US7 components, except tendon PD; steroid daily dosage was significantly reduced.

28 patients were considered Responders at 3 months: responders used to have higher disease activity levels and synovitis scores at baseline.

Table 1.

Comparisons demographics and renal pathologies of responder and non-responder groups

BL3Mp value6Mp valueRNRRNRRNRpainVAS67,88±23,3758,18±22,7230,19±23,5245,64±25,48p=0.004030,19±20,4229,73±22,15p=0.2105Daily prednisone equivalent5,97±5,575,45±4,302,96±3,023,95±3,63p=0.22481,63±2,103,03±3,59p=0.1247GSS8,50±5,257,00±3,813,69±3,632,33±2,45p=0.93343,56±3,014,22±2,64p=0.2452GST2,88±2,333,11±2,090,88±0,891,56±1,59p=0.65011,00±1,372,78±1,72p=0.0831PDS8,00±7,113,33±3,463,00±3,482,44±3,36p=0.00663,25±3,135,00±4,56p=0,0006PDT2,81±2,462,44±3,360,88±1,541,33±1,50p=0.449901,06±1,533,78±3,19p=0.0156Erosions1,25±2,050,44±0,731,50±2,030,44±0,73p=0.07361,31±2,091,11±1,27p=0.0902

Interestingly, painVAS and steroid dosage significantly decreased both in responders and non-responders, achieving similar value at 6 months. Non-responders showed both synovial and tendon involvement relapse at 6 months, with significantly higher PD score compared to responders. Remission was reached by 12,8% patients at 3 months and 21,6% at 6 months, while LDA patients were respectively 53,8% and 51,3%; combination with csDMARD was the only factor positively associated with remission/LDA at 3 months.

The percentage of dropped-out patients due to AE was aligned with literature data (5% in 6 months) whereas the percentage of Herpes Zoster Virus (HZV) infections was higher (4,6% in 6 months in our population vs 4,3% in 1 year in RCTs). Corticosteroid dosage was directly associated with AE development at 6 months.

Conclusion:

Real life data confirmed BARI RCTs efficacy and safety data. Non responders showed both synovial and tendon PD disease relapse, despite painVAS and steroid reduction were comparable to responders. In our population, HZV infection prevalence was higher than in RCTs and corticosteroid dosage was positively associated with AE development at 6 months.

Disclosure of Interests:

Giulia Tesei: None declared, Cosimo Bruni Speakers bureau: Actelion, Eli Lilly, Laura Cometi: None declared, Francesca Nacci: None declared, Marco Capassoni: None declared, Riccardo Terenzi: None declared, Lorenzo Tofani: None declared, Francesca Bartoli: None declared, Ginevra Fiori: None declared, Marco Matucci-Cerinic Grant/research support from: Actelion, MSD, Bristol-Myers Squibb, Speakers bureau: Acetelion, Lilly, Boehringer Ingelheim

Role of Co-occurring Alcohol and Substances Abuse on QTc Interval Prolongation Among Psychiatric Patients: A Cross-sectional National Survey

Introduction

QTc interval prolongation is considered a risk factor for fatal polymorphic ventricular tachycardia, which can result in sudden cardiac death. Most psychotropic drugs have a dose-dependent potential to prolong the QTc interval. However, other factors require appropriate consideration, including: age; gender; other medications; electrolyte abnormalities; severe comorbid conditions, such as co-occurring alcohol or substances abuse/dependence.

Objectives

The objective was to study the potential mediating roles of alcohol/substances abuse on QTc prolongation.

Aims

The Italian research group STAR Network, in collaboration with the Young Italian Psychiatrists Association, aimed to evaluate the frequency of QTc interval prolongation in a sample of patients under treatment with psychotropic drugs through a cross-sectional national survey.

Methods

A sample of 2411 unselected patients were enrolled after performing an ECG during the recruitment period. Sociodemographic and clinical characteristics were collected from medical records. Collected data underwent statistical analysis.

Results

A total of 11.2% of patients reported alcohol abuse, and only 8.9% psychotropic substances. According to the threshold, less than 20% of patients had a borderline value of QTc, and 1% a pathological value. Patients with co-occurring alcohol misuse and drug abuse were more likely to have longer QTc interval.

Conclusions

The present study describes the frequency of QTc prolongation in real-world clinical practice. Before prescribing a psychotropic drug, the physician should carefully assess its risks and benefits to avoid this type of adverse reaction, particularly when additional risk factors are present. The potential role of alcohol and substances on QTc length could be particularly useful in emergency settings.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

A cross-sectional nationwide survey on esophageal atresia and tracheoesophageal fistula

BACKGROUND

Our study aims at disclosing epidemiology and most relevant clinical features of esophageal atresia (EA) pointing to a model of multicentre collaboration.

METHODS

A detailed questionnaire was sent to all Italian Units of pediatric surgery in order to collect data of patients born with EA between January and December 2012. The results were crosschecked by matching date and place of birth of the patients with those of diagnosis-related group provided by the Italian Ministry of Health (MOH).

RESULTS

A total of 146 questionnaires were returned plus a further 32 patients reported in the MOH database. Basing on a total of 178 patients with EA born in Italy in 2012, the incidence of EA was calculated in 3.33 per 10,000 live births. Antenatal diagnosis was suspected in 29.5% patients. 55.5% showed associated anomalies. The most common type of EA was Gross type C (89%). Postoperative complications occurred in 37% of type C EA and 100% of type A EA. A 9.5% mortality rate was reported.

CONCLUSIONS

This is the first Italian cross-sectional nationwide survey on EA. We can now develop shared guidelines and provide more reliable prognostic expectations for our patients.

Neonatal laparoscopic inguinal hernia repair: a 3-year experience

PURPOSE

To retrospectively analyze the feasibility, safety and complication rate of laparoscopic inguinal herniorraphy in babies weighing 5 kg or less.

METHODS

Thirty infants weighing 5 kg or less underwent laparoscopic inguinal hernia repair during a 3-year period. Twenty-eight infants were born preterm and the mean body weight at surgery was 3,800 kg. Internal inguinal ring was closed with a non-absorbable purse-string suture. Contralateral processus vaginalis was closed if patent. Feeding was started on the same day and the patient discharged the following day. Follow-up consisted of physical examination at 1 week, 6 and 12 months post-operatively.

RESULTS

Of the 30 patients (27 males, 3 females), 11 had bilateral and 19 monolateral hernia (16 right, 3 left). At laparoscopy, 23 infants needed to have bilateral herniorraphies. The mean corrected gestational age at surgery was 49.1 weeks. The mean operative time for repair was 30 min for unilateral and 41 min for bilateral hernia. There were not intra- or post-operative complications as well as conversions or recurrences.

CONCLUSIONS

Laparoscopic inguinal hernia repair in newborns and in ex-preterm infants is a safe and effective procedure to perform and, perhaps, even less technically demanding than open herniotomy.

Sjögren's syndrome: correlation between histopathologic result and clinical and serologic parameters

AIM

Sjögren's syndrome (SS) represents a challenging illness to diagnose properly and, because of the serious complications such as lymphoma, it is important to reach a correct diagnosis in early stages. Aim of this retrospective study was to evaluate the correlation between histopathologic result of minor salivary gland biopsy and clinical and serologic parameters for the diagnosis of SS.

METHODS

We evaluated 360 biopsies, taken from the lower lip, of 360 patients (18 males) on suspicion that they were suffering from SS. The Chisolm and Mason classification was used to state the diagnosis of SS. For each patient, the medical history and the symptoms were evaluated, and diagnostic tests were performed. The revised rules of the American-European Consensus Group Criteria were used to diagnose primary and secondary SS. For the statistical analysis we used the Chi(2) test; a difference of P<0.05 was considered significant.

RESULTS

Considering the statistical correlation between a focal score > or =1 and the serological data, it was noted that a positive score was significantly correlated to all serological parameters examined (P<0.0001). A significant correlation was also found between a positive biopsy score and Schirmer's test and Rose Bengal test (P<0.0001). However, with regard to the clinical data, a significant correlation was found only for two parameters: xerostomia (P<0.0001) and parotid swelling (P<0.05).

CONCLUSION

Minor salivary gland biopsies are of great diagnostic value in detecting SS. However, for the diagnosis of SS both clinical and serologic parameters should be considered. The data obtained from the present survey reveal that the serologic markers are more predictive than clinical parameters for a positive biopsy score.

Xanthogranulomatous pyelonephritis is associated with higher tissue expression of monocyte chemotactic protein-1

TOPIC

Xanthogranulomatous pyelonephritis (XGP) is a chronic inflammation of the kidney characterized by destruction and replacement of its parenchyma with granulomatous tissue. It is associated with both chronic urinary obstruction and urinary tract infection (UTI).

METHODS

We studied two children with chronic ureteropelvic junction obstruction (UPJO) and recurrent UTI nephrectomized for poor kidney function. An intraoperative renal biopsy was taken to relate the presence of infiltrating monocytes plus tubular atrophy to tissue expression of monocyte chemotactic protein-1 (MCP-1) and epidermal growth factor (EGF). XGP was diagnosed by a pathologist in both cases.

RESULTS

MCP-1 expression was significantly higher in the two patients compared with the controls or patients with uncomplicated UPJO. It also correlated with the extent of monocyte infiltration, whereas EGF was only significantly downregulated when compared with the controls.

CONCLUSIONS

MCP-1 would seem to play a key role in the pathogenesis of XGP by mediating the recruitment of circulating monocytes or by cells resident in the interstitial space.

Angiotensin-converting enzyme I/D polymorphism and macrovascular disease in systemic sclerosis

OBJECTIVE

Systemic sclerosis (SSc) is characterized by microvascular and macrovascular alterations. The D allele of the ACE I/D polymorphism is known to be associated with an increased incidence of atherosclerosis and has been recently proposed as associated with increased risk of SSc. This study evaluates the relationship between intima-media thickness (IMT), ankle-brachial pressure measurements (ABPI) and ACE I/D polymorphism in SSc patients.

METHODS

According to the presence of ACE D allele (analysed by PCR), 53 SSc patients (47 females and 6 males; median age was 60.4 +/- 10.68 yrs; range 40-75 yrs) were divided in carriers of the D allele (DD + ID) (n = 46) and carriers of the I allele (II) (n = 7). In these patients, IMT and ABPI [calculated as the posterior tibial artery pressure (mmHg) divided by the brachial pressure] were obtained. Forty-three healthy controls (40 women and 13 men; median age 56.3 +/- 10.23; range 40-70 yrs) of the same ethnicity were recruited.

RESULTS

SSc patients had IMT significantly higher than controls (0.85 +/- 0.03 vs 0. 68 +/- 0.01; P < 0.03). No significant differences (P > 0.3) in ABPI values between patients (1.018 +/- 0.10) and controls (1.091 +/- 0.11) were found. SSc patients with ACE DD and ID genotype showed an IMT significantly greater (0.89 +/- 0.03) than those carrying the II genotype (0.61 +/- 0.01) (P < 0.04). ABPI was not different among ACE gene genotypes.

CONCLUSION

Our findings confirm an increased prevalence of macrovascular disease in SSc patients and show that IMT is greater in patients carrying the ACE DD and ID genotype in comparison with II homozygotes. This suggests that, in SSc, the presence of ACE D allele may predispose to an involvement of the macrovascular system.

Circulating levels of N -(carboxymethyl)lysine are increased in systemic sclerosis

OBJECTIVE

Advanced glycation endproducts (AGEs), including Nepsilon-(carboxymethyl)lysine-protein adducts (CML) are involved in micro/macrovascular changes and are co-localized with adhesion molecules in inflamed tissues. Serum levels of CML were investigated in systemic sclerosis (SSc) characterized by microvascular modifications and correlated with indices of micro/macrovascular damage.

METHODS

In 66 SSc patients (limited SSc, n = 55; diffuse SSc, n = 11) and 20 controls, CML serum levels were measured by enzyme-linked immunosorbent assay. Nailfold capillaroscopy, intima-media thickness (IMT) and the ankle-brachial index (ABI) were also recorded, to characterize micro/macrovascular involvement.

RESULTS

CML levels were significantly higher in SSc (79.2 +/- 39 mg/ml vs 49.6 +/- 26.1 mg/ml, mean +/- s.d.; P<0.01), without significant differences between SSc subsets. CML levels were significantly higher in all capillaroscopic patterns: the 'early' pattern showed higher levels than 'active' and 'late' patterns. IMT was significantly higher in SSc (P<0.01) than in controls, whilst ABI was no different from controls.

CONCLUSIONS

These data indicate that although both CML formation and macrovascular involvement are increased in SSc, there is no correlation between these two parameters. However, the characteristic early nailfold capillaroscopy changes of SSc are associated with proportionally greater CML formation, suggesting that AGEs are involved in SSc microangiopathy.

TPMT genotype and the use of thiopurines in paediatric inflammatory bowel disease

BACKGROUND

Thiopurines are used in the treatment of inflammatory bowel disease. They are metabolised via methylation by thiopurine-S-methyltransferase (TPMT), which displays a genetically determined polymorphic activity. Subjects with reduced TPMT activity have a higher concentration of active thiopurine metabolites and may be at increased risk of bone-marrow suppression.

AIMS

To evaluate the relevance of TPMT genotyping in the management of thiopurines therapy in inflammatory bowel disease patients.

PATIENTS AND METHODS

Adverse effects and clinical response were determined retrospectively and correlated with TPMT genotype in 70 paediatric inflammatory bowel disease patients.

RESULTS

Nineteen patients (27.1%) developed adverse effects; of the 51 who did not, 34 (66.7%) responded to treatment. Five patients (7.1%) were heterozygous for a variant TPMT allele; two of these (40%) were intolerant to thiopurines, compared to 17 of the 65 patients (26.2%) with a wild type gene (O.R. 1.88, 95% CI 0.29-12.2, p=0.61); among the 34 responders, the median dosage of the drug required to obtain remission was lower for mutated than for wild type patients (1.6mgkg(-1)day(-1) versus 2.0mgkg(-1)day(-1), p=0.043).

CONCLUSIONS

There was no significant association between adverse effects of thiopurines and TPMT heterozygous genotype, but TPMT genotyping could be useful in establishing the most appropriate dose of thiopurines to start treatment.

The fibrinolytic system components are increased in systemic sclerosis and modulated by Alprostadil (alpha1 ciclodestryn)

OBJECTIVES

To evaluate urokinase plasminogen activator (u-PA), urokinase plasminogen activator soluble receptor (su-PAR), plasminogen activator inhibitor 1 (PAI-1) and tissue plasminogen activator (t-PA) plasma levels in SSc patients (pts) versus healthy controls and their modulation by intravenous alphacyclodestrine (Alprostadil).

METHODS

Plasma levels of u-PA, su-PAR, PAI-1 and t-PA were measured in 40 SSc (34 lSSc and 6 dSSc) pts and in 30 healthy controls. In SSc, blood was drawn before and after 3 consecutive daily of Alprostadil infusion (60 mg in 250 cc NaCl 0.9%).

RESULTS

In SSc su-PAR basal levels were higher than controls (7.48 +/- 2.5 vs 4.69 +/- 0.4 ng/ml; p = 0.001) and were significantly reduced by Alprostadil (5.93 +/- 1.7; p = 0.002), but remain higher than controls (p = 0.03). u-PA basal levels were higher than controls (3.78 +/- 1.5 vs 1.29 +/- 0.3 ng/ml; p < 0.001) and were reduced by Alprostadil (2.39 +/- 1.7; p < 0.001) to control levels. SSc PAI-1 basal levels were lower than controls (31.60 +/- 7.7 vs 48.30 +/- 6.8 ng/ml; p < 0.001) and increased by Alprostadil (34.66 +/- 5.4; p = 0.04), but lower than controls (p < 0.001). SSc t-PA basal levels were higher in respect to controls (1645.81 +/- 792.7 vs 571.95 +/- 75.5 pg/ml; p < 0.0001) and reduced by Alprostadil (1318.06 +/- 603.5; p = 0.04), but still higher than controls (p = 0.001).

CONCLUSION

Fibrinolysis were increased in SSc. Infusions of Alprostadil modulate u-PA, su-PAR, PAI-1 and t-PA, restoring near normal levels. In SSc, fibrinolysis system may become a potential target for new therapies.

[Risk factors conditioning the incidence and severity of cyclosporine A-induced gingival overgrowth and methods of prevention]

Cyclosporin A (CsA) induced gingival overgrowth is one of the major side-effects conditioning the quality of life of the patient under immunosuppressive therapy. This adverse effect has been first reported in 1983 and affects almost 30% of treated patients. Several papers have been published concerning the cellular/molecular mechanisms by which CsA may induce, at the same time, an immunosuppressive and proliferative action. In this review various factors concerning the patient and his milieu that account for the different prevalence of the severity of gingival overgrowth in clinical studies are analyzed and briefly discussed. In particular, age, sex, pharmacokinetic properties, pharmaceutical preparation, genetic predisposition, association with other drugs and the parodontal conditions before transplantation are considered. In addition, a unique approach to the patients with gingival overgrowth as well as effective methods of prevention and therapy are suggested.